Provider Demographics
NPI:1871581637
Name:FU, JACKSON C (MD)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:C
Last Name:FU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:44241 15TH ST W
Mailing Address - Street 2:STE 303
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-4037
Mailing Address - Country:US
Mailing Address - Phone:661-948-4691
Mailing Address - Fax:661-949-5831
Practice Address - Street 1:44241 15TH ST W
Practice Address - Street 2:STE 303
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-4037
Practice Address - Country:US
Practice Address - Phone:661-948-4691
Practice Address - Fax:661-949-5831
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2011-12-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA41310207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A413100Medicaid
A85602Medicare UPIN
A41310Medicare ID - Type Unspecified